- 1. When symptoms are mild and not increasing in severity;
- 2. When pain and tenderness are not pronounced and gradually subside;
- 3. When the pulse rate does not exceed 100;
- 4. When temperature is not rising nor showing abrupt changes, especially if during the first thirty-six hours there have been no rise. (Murphy states that if there has been no temperature during the first thirty-six hours he begins to doubt the diagnosis.)
- 5. When the belly is not distending;
- 6. When rigidity is not increasing and there is no evidence of peritonitis;
- 7. When nausea is not increasing;
- 8. When neither in facial expression nor elsewhere are there evidences of septic infection;
- 9. When there is no perceptible tumor in the right iliac fossa.
Under the above conditions the conservative surgeon will be justified in waiting; being prompt, however, to intervene, should there be change for the worse in any one of the features specified. Even here it may be said that with conditions all as favorable as above represented pus may be present (in small quantity) and the whole picture may suddenly change into one of local disaster.
Finally it may be summed up in these words: When there is no doubt as to the advisability of waiting, then wait; but in case of doubt operate, i. e., give the patient the benefit of the doubt, which he in this way the more certainly obtains.
Non-operative Treatment.
—While thus waiting in cases which justify it, what should be done? Absolute rest in bed, even to the extent of using bedpan instead of commode, is the first essential. The second comprises abstention from all food, and practically the temporary starvation of the patient, who may be allowed water in abundance and nothing else. Altogether too much stress has been placed upon the so-called starvation treatment as “saving patients from operation.” Active therapeutic treatment is limited mainly to the use of cathartics and of anodynes, according to reason therefor. On one hand it is not advisable to rudely stir up the large intestine, one part of whose structure is already involved in a serious and questionable inflammatory process; on the other hand it is not for the general welfare of the patient to permit him to continue with a condition of coprostasis and the ever-increasing stercoremia which it encourages. On the whole it would seem better to clean out the lower bowel at the earliest possible moment, after which if the patient be properly starved there will be less necessity for subsequent active catharsis. The question of anodynes is one of equal importance. Those who bear pain badly, or those who suffer intensely, will demand anodynes, which every physician knows both help to mask the symptoms and interfere with elimination; but such cases seem to be of themselves so violent that the extreme expression of pain should of itself be regarded as an indication for operation. It should be held, then, that cases which demand opiates for relief of pain demand operation even more strongly. In the mild cases, expectantly treated, the local application of ice may be of some value. In effect these cases are to be treated expectantly, and, while expectant treatment is a confession of weakness or of ignorance, it may be unavoidable because early operation is flatly refused.
Indications for Operation.
—Sufficient reasons for not operating being absent or having passed, the following may be considered among the more urgent indications for immediate surgical attack:
- 1. Continued and especially increasing pain and tenderness;
- 2. A rapid pulse (110 or over) tending to increase in rapidity;
- 3. Any rapid change in the temperature, either a sudden rise or a drop to the normal or subnormal, without corresponding improvement in every other particular;
- 4. Increasing or widespread abdominal rigidity; when the right side of the abdomen of a sensible and non-neurotic subject is rigid this of itself should be sufficient to justify operation;
- 5. The appearance of tumor in the right iliac fossa;
- 6. Recurring and especially constant vomiting;
- 7. Any indication of septic infection, local or general.
Such are the indications by which the surgeon may say upon the instant of their recognition that a given case requires immediate operation. Fortunate are both he and the patient if the case be seen early, when these conditions have but lately shown themselves, and before it be too late. It has been said that almost every death from appendicitis means the loss of a life that might have been saved and for which someone is responsible, this responsibility being divisible among the patient, the parents or family, and the general practitioner who first saw the case and was tardy in recognizing its essential features. While patients die after late operations the surgeon himself is rarely censurable, it not being his fault that he was called in too late, and the patient dying of the progress of the disease in spite of an operation and not because of it.
Operation for appendicitis may be one of the simplest and easiest of the abdominal operations, especially when the acutely infectious element be not present, or it may be one of the most trying and difficult of all possible surgical procedures, taxing alike the judgment of the experienced operator and the resources of the clinic. Much will depend upon the time at which it is performed. If within the first forty-eight hours the surgeon may expect to find but a small amount of pus; if from the second to the fifth day, he may find a well-marked collection, while later he may have not only localized abscess but extensive complications. Again, he who operates between attacks, during the interval or interim stage, will find conditions of adhesion and results of old disease rather than its active products.